What's happening now! Telehealth management of spinal cord injury/disorders

Implementation of Video-Based Care in Interdisciplinary Primary Care Settings at the Veterans Health Administration: Qualitative Study

BACKGROUND

With the rapid shift to telehealth, there remains a knowledge gap in how video-based care is implemented in interdisciplinary primary care (PC) settings.

OBJECTIVE

The objective of this study was to gain an in-depth understanding of how video telehealth services were implemented in PC from the perspectives of patients and interdisciplinary PC team members at the Veterans Health Administration (VHA) 2 years after the onset of the COVID-19 pandemic.

METHODS

We applied a positive and negative deviance approach and selected the 6% highest (n=8) and the 6% lowest (n=8) video-using PC sites in 2022 from a total of 130 VHA medical centers nationally. A total of 12 VHA sites were included in the study, where 43 PC interdisciplinary team members (August-October 2022) and 25 patients (February-May 2023) were interviewed. The 5 domains from the diffusion of innovation theory and the nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework guided the development of the 2 study interview guides (provider and patient). We identified themes that emerged across all interviews that were associated with the implementation of video-based care in interdisciplinary PC settings, using directed-content rapid analysis of the interview transcripts. The analysis was guided by 5 a priori NASSS domains: (1) patient condition or characteristic, (2) technology, (3) adopter system, (4) health care organization, and (5) adaptation over time.

RESULTS

The study findings include the following common themes and factors, organized by the 5 NASSS domains: (1) patient condition or characteristic-visit type or purpose (eg, follow-up visits that do not require physical examination), health condition (eg, homebound or semihomebound patients), and sociodemographic characteristic (eg, patients who have a long commute time); (2) technology-key features (eg, access to video-enabled devices), knowledge (eg, how to use videoconferencing software), and technical support for patients and providers; (3) adopter system-changes in staff roles and clinical practice (eg, coordination of video-based care), provider and patient preference or comfort to use video-based care, and caregiver's role (eg, participation of caregivers during video visits); (4) health care organization-leadership support and access to resources, scheduling for video visits (eg, schedule or block off digital half or full days), and training and telehealth champions (eg, hands-on or on-site training for staff, patients, or caregivers); (5) adaptation over time-capacity to improve all aspects of video-based care and provide continued access to resources (eg, effective communication about updates).

CONCLUSIONS

This study identified key factors associated with the implementation of video-based services in interdisciplinary PC settings at the VHA from the perspectives of PC team members and patients. The identified multifaceted factors may inform recommendations on how to sustain and improve the provision of video-based care in VHA PC settings as well as non-VHA patient-centered medical homes.

Perspectives from the spinal cord injury community with teleSCI services during the COVID-19 pandemic: a qualitative study

PURPOSE

To explore individuals with spinal cord injury (SCI) experiences with and perceptions towards teleSCI services during the COVID-19 global pandemic in British Columbia, Canada.

METHOD

Using maximum variation sampling, we invited selected individuals from a larger quantitative dataset (n = 71) to partake in an interview. In total, 12 individuals participated in the study. Interviews were recorded and transcribed verbatim. Interview transcripts were then coded and analysed by team members using qualitative descriptive analysis.

RESULTS

Individuals with an SCI perceived teleSCI services to be convenient, accessible, affordable, and an effective way to access some healthcare services during the COVID-19 pandemic. However, in-person healthcare was still needed by many participants to effectively manage and treat their SCI-associated secondary conditions.

CONCLUSION

Our findings suggest that, in a post-pandemic world, the SCI community would benefit from blended models of healthcare delivery that leverage telecommunication technologies to increase accessibility to healthcare while still providing in-person care for assessments and treatments.Implications for RehabilitationIndividuals with an SCI perceived teleSCI services to be convenient, accessible, affordable, and an effective way to access some healthcare services during the COVID-19 pandemic. However, in-person healthcare was still needed and desired by those with an SCI to effectively manage and treat their SCI-associated secondary conditions.In a post-pandemic world, individuals with an SCI would benefit from blended models of healthcare delivery that leverage telecommunication technologies to increase accessibility to healthcare, while still providing in-person care for those requiring ongoing treatment and management of secondary conditions associated with the patient's SCI.TeleSCI services offer the potential to allow healthcare professionals and SCI specialists to collaborate (digitally) with patients at the same time. This patient-centered approach could not only help healthcare professionals strategize effective remedies to better manage secondary conditions associated with SCI but could result in overall better-quality care received by those within the SCI community.

Effect of Tele-exercise to Promote Empowered Movement for Individuals With Spinal Cord Injury (TEEMS) Program on Physical Activity Determinants and Behavior: A Mixed Methods Assessment

OBJECTIVE

To assess the effects of group tele-exercise participation on physical activity (PA) determinants and behavior as identified by social cognitive theory (SCT) in individuals with spinal cord injury (SCI).

DESIGN

This clinically registered non-randomized trial [NCT05360719] used a single-group parallel mixed methods design. Quantitative and qualitative primary measures were assessed at pre-program and after 8-week intervention completion (post-program), with an additional 8-week period retention to capture quantitative assessments only.

SETTING

Community.

PARTICIPANTS

Individuals with chronic SCI (N=22, injury duration 2-50 years) aged 26-68 years (10 male/12 female).

INTERVENTION

An 8-week group tele-exercise program for individuals with SCI consisting of biweekly 60-minute classes delivered via live Web-conferencing software.

MAIN OUTCOME MEASURES

Exercise self-efficacy (Exercise Self-efficacy Scale for SCI: ESES), outcome expectations for exercise (Multidimensional Outcome Expectations for Exercise: MOEES), weekly PA minutes measured through quantitative assessments (Leisure Time PA Questionnaire for SCI: LTPAQ), and parallel qualitative thematic analysis of focus group interview transcripts.

RESULTS

Congruence between numeric and thematic findings was present for exercise self-efficacy and self-evaluative exercise outcome expectations. Improved exercise self-efficacy was influenced by exercise knowledge gained during program participation. Increased expectations of internal exercise outcomes, such as influence on psychological state and overall mood, occurred after program participation. Participant descriptions of the portability and sustainability of the program leading to added movement in everyday life were not reflected in the numeric scores of LTPAQ assessment.

CONCLUSIONS

Participation in an 8-week group tele-exercise program positively affected personal determinants of PA behavior immediately after participation. Future investigations should include a control group and biophysical PA measures such as wearable digital health devices.

Development and Feasibility of a Group Tele-Exercise Program for Individuals With Spinal Cord Injury

BACKGROUND AND PURPOSE

More than 50% of individuals with spinal cord injury (SCI) report no regular exercise due to numerous barriers to participation. Tele-exercise services offer viable solutions to reduce barriers. However, limited evidence for SCI-specific tele-exercise programs is available. The purpose of this study was to evaluate the feasibility of a synchronous group tele-exercise program designed for individuals with SCI.

METHODS

Explanatory sequential mixed-methods design assessed feasibility of a synchronous 2-month biweekly group tele-exercise program for individuals with SCI. Numeric measures of feasibility were first collected (recruitment rate, sample features, retention, attendance), followed by postprogram interviews with participants. Thematic analysis of experiential feedback elaborated on numeric findings.

RESULTS

Eleven volunteers (ages = 49.5 ± 16.7 years) with SCI (range: 2.7-33.0 years) enrolled within 2 weeks of recruitment initiation. Retention was 100% retention at program completion. Median number of live classes attended per participant was 10 (62.5%). Participants described that attendance and satisfaction were facilitated by program-specific features including coinstruction by instructors with SCI-specific knowledge and lived experience, as well as group structure. Participants reported increased exercise knowledge, confidence, and motivation.

DISCUSSION AND CONCLUSIONS

This study demonstrated feasibility of a synchronous group tele-exercise class for individuals with SCI. Key features facilitating participation include class length, frequency, coleadership by individuals familiar with SCI and exercise instruction, and group motivation. These findings begin to examine a viable tele-service strategy that could be employed as a bridge among rehabilitation specialists, community fitness instructors, and clients with SCI to increase physical activity access and behavior.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A442 ).

Synchronous and asynchronous tele-exercise during the coronavirus disease 2019 pandemic: Comparisons of implementation and training load in individuals with spinal cord injury

INTRODUCTION

Tele-exercise could represent an alternative for remote care in individuals with spinal cord injury at this time of the pandemic of coronavirus disease 2019. However, the differences regarding the training loads and implementation between synchronous and asynchronous types are not yet known. The purpose of this study was to compare the implementation and training load between synchronous and asynchronous tele-exercise programs in individuals with spinal cord injury.

METHODS

Forty individuals with spinal cord injury were recruited and stratified into tetraplegia and paraplegia groups. All subjects performed 3 weeks of both the synchronous and asynchronous tele-exercise programs, after two weeks of familiarization with the exercises, remote connection tools and methods to record information. The primary outcomes were training load (average daily workload and average and total weekly training load) and implementation (adherence and successful exercise recording). Demographic characteristics were obtained from participants' electronic medical records.

RESULTS

Weekly mean workload, total workload, adherence and successful exercise recording presented significantly higher values in the synchronous compared to asynchronous tele-exercises. Average daily workload did not present significant differences between the tele-exercises.

DISCUSSION

The training load for each training session presented no differences between synchronous and asynchronous tele-exercises. Both adherence and successful data recording showed more favourable implementation values for synchronous training, thus allowing greater weekly training loads (total and average).

Primary Care in the Spinal Cord Injury Population: Things to Consider in the Ongoing Discussion

Purpose of Review

Spinal cord injury (SCI) creates unique needs that if not recognized and addressed timely can have detrimental effects on the health and quality of life (QOL) of people living with a SCI. Primary preventive health care is shown to decrease morbidity and mortality, yet the SCI population reportedly faces challenges getting access to this care. This area in SCI health care is still largely understudied with no consensus on the ideal way or which health care provider is best to provide primary care for this population.

Findings

Preventive care is generally provided by general primary care providers, but not all primary care providers are trained in recognizing and addressing spinal cord injury-specific needs. SCI providers generally are not trained in addressing all aspects of preventive care. Knowing the recommended preventive care screenings, recognizing and managing specific conditions seen after a SCI, and seamless coordination of care between general practitioners and SCI specialists are some of the interventions to help prevent health complications, decrease morbidity and mortality, improve health outcomes, and promote QOL in this patient population.

Summary

Prioritized focus on preventive care is necessary for a positive impact on the overall health and QOL in this population. Addressing the knowledge gap reported by primary care providers and SCI providers may help increase the probability of SCI patients getting their preventive and specialty care needs addressed. We present a "cheat sheet" of recommendations for the preventive care evaluation of a person living with a SCI.

"You were lying in limbo and you knew nothing": a thematic analysis of the information needs of spinal cord injured patients and family members in acute care

PURPOSE

To address the lack of research on the information needs of spinal cord injured (SCI) patients and family members in acute care, in order to inform the provision of appropriate information supports.

MATERIALS AND METHODS

Semi-structured interviews were conducted with seven traumatic SCI patients and six family members. Reflexive thematic analysis was used to analyse and interpret the data.

RESULTS

Five themes were generated: (1) "You were lying in limbo and you knew nothing" describes how being situated in non-specialist acute care limited participants' access to information; (2) "You'll never walk again" is not enough describes the need for information about the effects of SCI and the management of secondary conditions; (3) "The delivery was awful" demonstrates the importance of information being explained clearly and empathically; (4) "It was going in one ear and out the other" highlights the need for ongoing conversations with healthcare professionals, as retaining information provided in the early stages post-injury is often difficult; and (5) "Hope" not "false hope" discusses the importance of giving patients and family members hope while simultaneously being realistic about potential recovery.

CONCLUSIONS

SCI patients and family members had significant unmet information needs in acute care.IMPLICATIONS FOR REHABILITATIONSCI patients and family members had significant unmet information needs while in acute care. Being in non-specialist acute care significantly limited most participants' access to information.During the acute phase of care, most patients and family members would like to know the patient's recovery prognosis, the impact of SCI on the patient's functional independence, how to manage secondary complications, and what to expect in rehabilitation.As patients and family members often had difficulty absorbing information in the early stages post-injury, information should be continuously repeated, reinforced and clarified.HCPs should promote realistic hope for SCI patients and family members even in the absence of neurological recovery, by focusing on what the patient is still capable of while being honest about their prognosis.

Nutrition counseling and monitoring via tele-nutrition for healthy diet for people with spinal cord injury: A case series analyses

OBJECTIVE

To evaluate the effect of a tele-nutrition counseling program on diet quality, weight, waist circumference, and quality of life in people with spinal cord injury (SCI).

DESIGN

Prospective observational study.

PARTICIPANTS

Fifteen participants with SCI were enrolled from an acute inpatient rehabilitation unit and outpatient SCI clinic; ten participants completed the intervention.

INTERVENTIONS

Six tele-nutrition counseling sessions over 3 months, utilizing videoconferencing and a photographic food diary.

OUTCOME MEASURES

Weight, waist circumference, Life Satisfaction Index A (LSIA), Knowledge and Nutrition Evaluation with Supplement on Eating Behavior, and Program Satisfaction Survey (PSS).

RESULTS

Ten participants completed both baseline and 3-month follow-up evaluations and were used in this analysis. There were no statistically significant changes from baseline to 3-month follow up in weight, waist circumference, Knowledge and Nutrition Evaluation, and LSIA (P > .48). Using the Supplement on Eating Behavior total score to measure overall changes in healthy food choices, 9 out of 10 participants rated their healthy food choices as improving (P = .008). A post-hoc exploratory itemized analysis on the Supplement on Eating Behavior revealed significant improvements from baseline to 3-month follow-up in participant's self-reported choice of balanced meals (P = .008), reading food labels (P = .031), logging meals (P = .007), and monitoring portions of eating favorite foods (P = .031). Participants endorsed a 97-100% satisfaction rating in relation to perceived health benefits, equipment, and program satisfaction.

CONCLUSION

This study provides preliminary data suggesting that tele-nutrition is an efficacious intervention that may improve diet quality for individuals with SCI.

Videoconferencing in Pressure Injury: Randomized Controlled Telemedicine Trial in Patients With Spinal Cord Injury

Background

Geographical, financial and travel-related barriers may impact access to necessary health care for people in need of long-term follow-up.

Objective

The goal of the research was to perform a nonblinded, randomized, controlled trial on health-related quality of life (HRQoL), healing, interaction, and satisfaction of patients with spinal cord injury (SCI) and PI receiving multidisciplinary videoconference consultations from a wound clinic to the participant’s home versus regular outpatient care. The multidisciplinary team consisted of a medical doctor, a wound nurse, and an occupational therapist. In both groups, district nurses attended the consultations at the participant’s home.

Methods

A total of 56 participants, 28 in each group, were randomized to a videoconference group (VCG) or a regular care group (RCG). Validated questionnaires were used to measure and compare the follow-up effect on HRQoL. Percentage reduction of wound volume was measured at end of the follow-up. A Likert scale was used to measure the satisfaction of the patients and district nurses regarding the interaction between different modalities of care in the 2 groups.

Results

The HRQoL did not show significant differences between the 2 groups (P values ranging from .09 to .88) or the rate of PI healing, experienced interaction, and satisfaction in the groups. A total of 67% (37/55) of all PIs healed, 64% (18/28) in the VCG and 70% (19/27) in the RCG. Mean reduction in ulcer volume was 79% in the VCG and 85% in the RCG (P=.32). A Kaplan-Meier plot with a logrank test regarding time to healing did not show any significant difference between the 2 groups.

Conclusions

Videoconference-based care seems to be a safe and efficient way to manage PIs in terms of HRQoL, healing, interaction, and satisfaction compared to conventional care for people with SCI. This should be considered when planning for future care. SCI has a huge impact on the individual, the family, and the health care system. There is an urgent need to improve systems of care so that individuals who live far from specialists and require long-term follow-up for conditions such as PI can get optimal treatment.

Trial Registration

ClinicalTrials.gov NCT02800915; https://clinicaltrials.gov/ct2/show/NCT02800915 and Current Research Information System in Norway (CRISTIN) 545284; https://app.cristin.no/projects/show.jsf?id=545284

Investigating the Challenges and Benefits of Engaging in Peer Support via Videoconferencing for People with Spinal Cord Injury

BACKGROUND

One of the greatest challenges faced by people following a spinal cord injury is reintegrating into the community. Peer mentors are people who have had shared experiences of disadvantage and distress and have successfully navigated their way through the associated challenges to lead meaningful lives. Historically, peer mentoring services have been predominantly delivered via face-to-face interactions. Little is known about the experience of people with spinal cord injury engaging in online peer support services, and what the challenges and benefits are of this mode of delivery.

METHODS

An anonymous online survey consisting of closed and open response questions was used to collect data. Quantitative data were analysed descriptively and qualitative data were analysed using inductive content analysis.

RESULTS

Positive benefits of engaging in peer support via videoconferencing included convenience and social connectedness. The main barriers were problems with Wi-Fi and internet connections, inconsistencies between platforms and having to learn new platforms. Even though responses were mixed when comparing videoconferencing to face-to-face peer support, most participants felt socially connected.

CONCLUSIONS

Addressing barriers through the provision of appropriate technology, and targeted and individualised assistance, is important to facilitate uptake of online peer support for people with spinal cord injury.

The Legal and Socioeconomic Considerations in Spine Telemedicine

Telemedicine has become indispensable in today's health care because of the recent ongoing COVID-19 crisis. Although it has been beneficial in coping with the pandemic, there is still much uncertainty as to whether it will have a permanent role in treating spine patients. Some of the ongoing legal challenges include patient confidentiality, liability coverage for treating healthcare workers, and financial reimbursements by insurance companies. One of the impediments of telemedicine is its lack of a standard legal framework. Telehealth is currently regulated through a state-based system with each state having its own policy regarding this practice. In addition, each of the components of a virtual visit represent a potential area for legal concerns. Nonetheless, telemedicine has the ability to provide convenient and effective health care to patients. However, the spine surgeon, as well as other physicians, must consider the legal issues along with some socioeconomic factors identified herein. Moreover, without parity and uniformity, the incentive to offer telehealth services decreases. There may be a need for modifications in the law, insurance policies, and medical malpractice coverage to strengthen their support to telemedicine usage. As spine surgeons become more familiarized with the telemedicine framework, its role in patient care will likely expand.

Current Approaches in Telehealth and Telerehabilitation for Spinal Cord Injury (TeleSCI)

Purpose of Review

Telehealth and telerehabilitation in spinal cord injury (teleSCI) is a growing field that can improve access to care and improve health outcomes in the spinal cord injury population. This review provides an overview of the recent literature on the topic of teleSCI and provides insights on current evidence, future directions, and considerations when using teleSCI for clinical care.

Recent Findings

TeleSCI is used most often for preventive health; management of chronic pain, anxiety, and depression; and rehabilitation-related interventions. As video telehealth becomes mainstream, growth in wearable monitors, bio and neurofeedback mechanisms, and app-based care is expected.

Summary

TeleSCI is growing in prevalence, demonstrates positive impact on health outcomes, and requires ongoing study to identify, refine, and implement best practices.

Telemedicine: An Innovative Twist to Primary Health Care in Rural Bangladesh

BACKGROUND

Health care service is worsening in the remote villages due to less complete and further away of healthcare facilities and service and makes this service costs compared to those of urban people. Telemedicine service provides a potential solution regarding this particular issue. This study provides empirical evidence of the benefits package consists of hypothetical telemedicine service and evaluates the economic benefit of telemedicine service.

METHODS

The study measures marginal willingness-to-pay (MWTP) responses to policy change on a sample (n = 203) observations. A randomized conjoint experiment has conducted in 7 remote villages of 3 coastal districts of the southwest coastal region of Bangladesh. Each respondent ranks 3 options-two hypothetical alternatives and the telemedicine status quo scheme. The level of attributes-payment for telemedicine service, sample collection from home, medicine delivery to home, capitation through online technology, service delivery frequency, and blood pressure and glucose measure at home-are randomly and jointly assigned to the 2 alternatives.

RESULTS AND CONCLUSIONS

Coastal villagers would like to pay more in option 4 and above. The lower payment for telemedicine service does not necessarily imply low demand for telemedicine, as the findings from MWTP illustrate potential demand for telemedicine in coastal villages in Bangladesh.

Reactive Oxygen Species and Pressure Ulcer Formation after Traumatic Injury to Spinal Cord and Brain

Traumatic injuries to the nervous system, including the brain and spinal cord, lead to neurological dysfunction depending upon the severity of the injury. Due to the loss of motor (immobility) and sensory function (lack of sensation), spinal cord injury (SCI) and brain injury (TBI) patients may be bed-ridden and immobile for a very long-time. These conditions lead to secondary complications such as bladder/bowel dysfunction, the formation of pressure ulcers (PUs), bacterial infections, etc. PUs are chronic wounds that fail to heal or heal very slowly, may require multiple treatment modalities, and pose a risk to develop further complications, such as sepsis and amputation. This review discusses the role of oxidative stress and reactive oxygen species (ROS) in the formation of PUs in patients with TBI and SCI. Decades of research suggest that ROS may be key players in mediating the formation of PUs. ROS levels are increased due to the accumulation of activated macrophages and neutrophils. Excessive ROS production from these cells overwhelms intrinsic antioxidant mechanisms. While short-term and moderate increases in ROS regulate signal transduction of various bioactive molecules; long-term and excessively elevated ROS can cause secondary tissue damage and further debilitating complications. This review discusses the role of ROS in PU development after SCI and TBI. We also review the completed and ongoing clinical trials in the management of PUs after SCI and TBI using different technologies and treatments, including antioxidants.

COVID-19 and spinal cord injury and disease: results of an international survey as the pandemic progresses

STUDY DESIGN

An online survey.

OBJECTIVES

To follow-up with and re-query the international spinal cord community's response to the Coronavirus Disease 2019 (COVID-19) pandemic by revisiting questions posed in a previous survey and investigating new lines of inquiry.

SETTING

An international collaboration of authors and participants.

METHODS

Two identical surveys (one in English and one in Spanish) were distributed via the internet. Responses from both surveys were pooled and analyzed for demographic and response data.

RESULTS

Three hundred and sixty-six respondents were gathered from multiple continents and regions. The majority (63.1%) were rehabilitation physicians and only 12.1% had patients with spinal cord injury/disease (SCI/D) that they knew had COVID-19. Participants reported that the COVID-19 pandemic had caused limited access to clinician and support services and worsening medical complications. Nearly 40% of inpatient clinicians reported that "some or all" of their facilities' beds were being used by medical and surgical patients, rather than by individuals requiring inpatient rehabilitation. Respondents reported a 25.1% increase in use of telemedicine during the pandemic (35% used it before; 60.1% during), though over 60% felt the technology incompletely met their patients' needs.

CONCLUSION

The COVID-19 pandemic has negatively impacted the ability of individuals with SCI/D to obtain their "usual level of care." Moving forward into a potential "second wave" of COVID-19, patient advocacy and efforts to secure access to thorough and accessible care are essential.

Triangle of Healthy Caregiving for Veterans With Spinal Cord Injury: Proposal for a Mixed Methods Study

Background

Spinal cord injury (SCI) is a debilitating injury that results in chronic paralysis, impaired functioning, and drastically altered quality of life (QOL). The Department of Veterans Affairs (VA) estimates that approximately 450 newly injured veterans and active-duty members receive rehabilitation at VA’s Spinal Cord Injury/Disorders Centers annually. VA virtual health services use technology and health informatics to provide veterans with better access and more effective care management. The “Triangle of Healthy Caregiving for SCI Veterans” is a patient-centered intervention that incorporates SCI veterans’ caregivers into the VA SCI health care team and extends into the homes of veterans with SCI by using real-time clinical video teleconferencing (CVT). CVT facilitates video-clinic visits, which can include different types of clinical evaluations, therapy (physical/occupational), or psychosocial services. The “Triangle of Healthy Caregiving for SCI Veterans” builds on interactive, interdisciplinary health care relationships that exist between the veterans with SCI, their caregivers, and the VA SCI health care team. SCI veterans’ propensity to multiple secondary complications makes a healthy partnership crucial for the success of keeping better health and functional outcomes as well as quality of life while living in their homes.

Objective

The goal of the proposed mixed methods project will assess SCI veterans’, their caregivers’, and the VA health care team’s perspectives and experiences in the “Triangle of Healthy Caregiving for SCI Veterans” to determine the benefits, challenges, and outcomes for everyone involved in the intervention.

Methods

Data collection methods will be implemented over three sequential phases. First, in-depth interviews will be conducted with the telehealth coordinators to systematically document the administrative procedures involved in enrollment of veterans with SCI into the CVT system. Next, structured observation of the CVT enrollment process and logistics of home installation of the CVT system will be conducted to validate the content of the in-depth interviews and highlight any discrepancies observed. Semistructured interviews will be conducted to assess specific elements of the “Triangle of Healthy Caregiving for SCI Veterans” program, their perceived utility, and effectiveness of the CVT system as well as the general impressions of the impact of the intervention on the SCI veterans’ health and function outcomes, caregiver burden, and daily caregiver burden. Finally, the research team will conduct a focus group to evaluate the ways in which the “Triangle of Healthy Caregiving for SCI Veterans” is useful for health care delivery to veterans with SCI and support services to SCI caregivers.

Results

This proposal was funded in July 2017. It was reviewed and received institutional review board approval in March 2018, and the project was started immediately after, in the same month. As of September 2019, we have completed Phases I and III and have recruited 52 subjects for Phase II. We are beginning the data analysis. The study is projected to be completed in late summer of 2020, and the expected results are to be published in the fall of 2020.

Conclusions

The findings from this study will highlight the ways in which virtual health care technologies can be used to improve access to SCI specialized care for veterans and provide an estimation of the potential impact on clinical outcomes for veterans with SCI and their caregivers.

International Registered Report Identifier (IRRID)

DERR1-10.2196/14051

Telemedicine for pediatric physiatry: How social distancing can bring physicians and families closer together

The coronavirus (COVID-19) pandemic triggered wide scale implementation of telemedicine in the United States. The government response, Coronavirus Aid, Relief, and Economic Security (CARES) Act, permitted loosening of existing restrictions on telemedicine enabling its rapid incorporation into the delivery of medical care for children and adults. Prior to COVID-19, few pediatric physiatrists had opportunities to access high fidelity telemedicine platforms to provide health care for patients with special needs, mobility impairments, developmental delays, neuromuscular disorders or other complex medical conditions. This literature review will explore how telemedicine can optimize health care delivery options for pediatric physiatrists in various inpatient and outpatient settings such as consultations, acute inpatient units, outpatient clinics and long-term care facilities. Detailed analysis of the current research in telemedicine applications as well as a critical review of the limitations and barriers for its use offers a plethora of opportunities for enhancement of continuity and coordination of care. Telemedicine may decrease healthcare disparities and increase access of care for children with special needs. Additional research is needed to assess the efficacy of telemedicine when addressing complex medical conditions in children.

Translating a spinal cord injury self-management intervention for online and telehealth delivery: A community-engaged research approach

Objective: To develop educational content and pilot test the use of tablet computers (iPads), online content management platform (iTunes U) and video conferencing (FaceTime) for delivery of a peer supported, spinal cord injury self-management intervention, using a community-engaged research approach. Design: Cross-sectional convenience sampled pilot study; evaluation using a combination of observation and questionnaires. Setting: Community-based. Participants: Individuals with SCI (n = 10) recruited from the community. Interventions: Participants engaged in a hands-on evaluation of the educational content and technology. Outcome Measures: Usability and acceptability of educational content and technology. Results: Participants were receptive and satisfied with the iPad and iTunes U platform and the video chat experience. Statements by our participants demonstrated a clear preference for interactive and multimedia platforms to promote engagement with educational materials. The use of FaceTime to facilitate contact between the participant and PN demonstrated satisfactory usability and acceptability. The hands-on evaluation process highlighted the need for consideration of connectivity for rural participants and assistive technology needs. Conclusion: Our community-engaged research approach and evaluation processes provided direct user feedback on the online and telehealth implementation of PHOENIX that will guide development of the remaining educational content, and testing of the intervention in a future feasibility trial.

Home-Based Rehabilitation Programs: Promising Field to Maximize Function of Patients with Traumatic Spinal Cord Injury

BACKGROUND

Traumatic spinal cord injury (TSCI) has profound effects on the patient's health condition and function. However current treatment strategies fail in terms of cure. Thus, rehabilitative management has become the main gadget to promote patients' residual function. The most challenging aspect of rehabilitation is high costs of inpatient rehabilitation programs and poor continuity of care while patients are transferred to home. In this regard, numerous home based rehabilitation programs have been introduced.

OBJECTIVES

This review is an attempt to better introduce and classify different aspects of home care programs for patients with TSCI all around the world.

METHODS

A literature search was conducted in the PubMed, Medline, and Google Scholar database. Studies that addressed rehabilitative programs for patients with TSCI in their home or home-like facilities were reviewed. Reference lists from retrieved articles were also reviewed.

RESULTS

Home based rehabilitation can be categorized in five different but naturally relevant fields: home aids/modification, home nursing and family help, social support, home based primary care (multidisciplinary physician groups), and novel models/methods (e.g. "transitional rehabilitation" or telemedicine).

CONCLUSION

Since most investigators in TSCI home based rehabilitation have only introduced their findings, there are no comparative studies available. Thus future studies should be dedicated to clinical trials evaluating clinical efficacy of different strategies. A comprehensive integrated strategy with consideration to financial and other limitations should be applied to each specific area.

Facilitators and Barriers for Implementing an Internet Clinic for the Treatment of Pressure Injuries

Background: Pressure injuries (PIs) represent a frequent, often preventable, secondary complication of spinal cord injury (SCI) with serious consequences to health, societal participation, and quality of life. Specialized knowledge and service delivery related to treatment and prevention are typically located within major health centers. Introduction: For persons with SCI living at home, it can be challenging to access specialized PI care. A telehealth approach could help mitigate this challenge. This multisite pilot investigation assessed the feasibility of integrating information technologies within the management of PIs. Materials and Methods: Each study site formed a specialized interdisciplinary care team that identified components of their standard clinical care pathway and examined how they could be integrated with study technologies. A monitoring system was utilized to enable patients and caregivers to exchange clinical information with the care team. Results: Clinician and patient focus groups were completed to identify facilitators and barriers for long-term implementation. Findings demonstrate that this method of service delivery is feasible but requires further development. Discussion: This model of care requires refinement to address technological, regulatory, and clinician acceptance barriers; however, increased access to these services has the potential for improving PI healing or prevention rates in comparison with those not able to access specialized services. Conclusions: This project demonstrates that PI treatment services can be delivered effectively through the internet. Future trials can investigate efficacy and cost-effectiveness of this model of care to inform sustained implementation.

The impact of personal and environmental factors on the rehabilitation of persons with neglected spinal cord injury in Malaysia

Introduction

Managing neglected spinal cord injury (SCI) patients in a rural setting can be challenging due to a lack of resources and the unique personal and environmental contextual factors that may hinder rehabilitation. This article aims to identify the contextual factors and their impact on successful rehabilitation.

Case presentation

A middle-aged man from a rural area had suffered a neglected traumatic SCI and was first seen by the rehabilitation team 17 years post injury. He had a T7 AIS A paraplegia and was bedridden with multiple secondary complications. He was admitted with goals of optimizing his health, initiating basic spinal rehabilitation and improving his functional status. By 1 month, the patient made gradual improvement of his mobility and ADL but requested discharge despite not having achieved his rehab goals. We identified the factors that contributed to his poor motivation to be more functionally independent. Personal factors include poor educational level, his background personality and erratic health-seeking behaviour. Environmental factors included poor family and financial support, physical barriers, lack of work opportunities and facilities for people with disability, poor community support and acceptance and poor healthcare facilities and expertise.

Discussion

The patient's personal and environmental factors affected the delivery of SCI management, spinal rehabilitation and management of secondary comorbidities. Awareness of early spinal rehabilitation among the rural community and healthcare authorities is crucial to promote better implementation of policies, services or programs to support people with SCI.

Telemedicine using an iPad in the spinal cord injury population: a utility and patient satisfaction study

Study design

Prospective observational.

Objectives

To explore participants' experience, satisfaction, and utility of telemedicine.

Setting

Spinal cord injury (SCI) rehabilitation clinic at a county hospital.

Methods

Participants in this study received telemedicine appointments for routine scheduled care and/or urgent consults with a spinal cord injury specialist via iPad on FaceTime. Demographic changes, health care utilization, and medical complications were assessed. A Program Satisfaction Survey (PSS) was completed after a 6-month enrollment.

Results

Telemedicine visits included general follow-ups (51.25%), "multiple issues" (24.38%), skin (6.88%), bowel and bladder (5.63%), spasms (3.13%), and pain (3.13%). The PSS was collected (n = 45) and revealed positive results in perceived health, satisfaction with equipment/ease of use, and satisfaction with the program. Analysis of anecdotal comments revealed themes such as efficiency, convenience, and reduced barriers provided by telemedicine visits.

Conclusions

This study shows the feasibility and acceptance of a telemedicine intervention via iPad for individuals with SCI through positive PSS ratings and the wide variety of clinical topics addressed.

Sponsorship

Craig H. Neilsen Foundation.

Experiences With Navigating and Managing Information in the Community Following Spinal Cord Injury

Background: People living with spinal cord injury (SCI) have reported difficulties managing information in the community, which can negatively impact their functional independence and ability to prevent secondary complications. Objective: This exploratory qualitative study aimed to describe the experiences of people living with SCI with navigating and managing information in the community from their perspective. Methods: Participants were recruited through the Australian Quadriplegic Association. Twenty-two semi-structured in-depth interviews were conducted with purposively selected participants to ensure representation of age, gender, SCI level, and compensation status. Data were thematically analyzed using a framework approach. Results: People living with SCI reported using multiple, complementary sources of information to prevent and manage secondary conditions. Over time, they learned to appraise the content, relevance, timing, and sources of information. Information delivered by health professionals in the rehabilitation setting was appraised as lacking personalization, but it acted as a springboard to search for more relevant information. Participants described the process of becoming experts about their condition to overcome the lack of knowledge of many general practitioners, guide their own care, and act as a source of information for others. Due to a lack of information provision, some participants missed health improvement opportunities and experienced frustration at the uncertainty of their future with SCI. Conclusion: Greater support is required for individuals with SCI to navigate information sources in the community. Rehabilitation is an opportune time to provide education related to finding and appraising information. Improved access to community health providers with SCI knowledge is also required.

Telehealth in Physical Medicine and Rehabilitation: A Narrative Review

Telehealth refers to health care interactions that leverage telecommunication devices to provide medical care outside the traditional face-to-face, in-person medical encounter. Technology advances and research have expanded use of telehealth in health care delivery. Physical medicine and rehabilitation providers may use telehealth to deliver care to populations with neurologic and musculoskeletal conditions, commonly treated in both acute care and outpatient settings. Patients with impaired mobility and those living in locations with reduced access to care may particularly benefit. Video-teleconferencing has been shown to be effective for management of burn patients during acute rehabilitation, including reduced health care use expenses and less disruptions to care. Telehealth can facilitate developing interprofessional care plans. Patients with neurologic conditions including stroke, spinal cord injury, traumatic brain injury, and amyotrophic lateral sclerosis may use telehealth to monitor symptoms and response to treatment. Telehealth also may facilitate occupational and physical therapy programs as well as improve weight management and skin care in patients with chronic conditions. Other applications include imaging review in sports medicine, symptom management and counseling in concussion, traumatic brain injury, and pain management programs. Limitations of telehealth include barriers in establishing relationship between medical provider and patient, ability to perform limited physical examination, and differences in payment models and liability coverage. The expansion of telehealth services is expected to grow and has potential to improve patient satisfaction by delivering high quality and value of care.

SCiPad: Effective Implementation of Telemedicine Using iPads with Individuals with Spinal Cord Injuries, a Case Series

Background

Individuals with spinal cord injury (SCI) must often travel long distances to see a rehabilitation specialist. While telemedicine (TM) for pressure ulcer management has been used in this population, real-time video telecommunication using iPad has never been described.

Objective

The objective of this study was to provide specialized care for persons with SCI through TM consultation expediently in order to address medical needs, manage secondary complications, and to improve quality of life (QoL) of individuals with SCI.

Methods

Ten individuals with SCI participated in the TM program using iPads for 6 months as a feasibility study at a single-center, county hospital. The participants contacted the project staff for SCI-related conditions and were then connected to an SCI-trained health-care provider within 24 hours via FaceTime. Main outcome measures included health-care utilization; QoL and psychosocial measures collected at baseline and at 6 months: Reintegration to Normal Living Index (RNLI), Life Satisfaction Index A (LSI-A), and Patient Health Questionnaire 9 (PHQ-9); and a Program Satisfaction Survey.

Results

Ten patients (seven with tetraplegia, three with paraplegia; eight males and two females) with an average age of 34.4 (18–54) years were enrolled. The average baseline and 6-month follow-up scores were RNLI—70.1 ± 19.7 and 74.7 ± 21.8, respectively; LSI-A—25.4 ± 7.4 and 26.4 ± 8.2, respectively; and PHQ-9 were 6.8 ± 7.2 and 8.6 ± 6.1, respectively. TM encounters included topics such as pain, bladder and skin management, medication changes, and lab results. The Program Satisfaction Survey yielded positive results with 100% of program completers stating they would recommend the program and would like to continue having TM.

Conclusion

This is the first known successful project using iPad to provide TM in the SCI population. This study discusses the implementation of such a TM program in a health system including limitations. It describes the clinical viability of TM using iPads in the SCI population for care beyond that of just pressure ulcer management. This project provides evidence for using a tablet device like an iPad as an effective and efficient patient management tool.

Sociotechnical Perspective on Implementing Clinical Video Telehealth for Veterans with Spinal Cord Injuries and Disorders

BACKGROUND

Real-time videoconferencing technology such as clinical video telehealth (CVT) offers a means to reach patient populations who face limited access to healthcare. The Veterans Health Administration has invested in CVT to improve care access for U.S. military veterans with spinal cord injuries and disorders (SCI/D); however, no studies have assessed the factors that influence implementation of this technology in clinical practice for individuals with SCI/D.

INTRODUCTION

Guided by a sociotechnical perspective, the purpose of this study was to identify factors that influence implementation of CVT for veterans with SCI/D.

MATERIALS AND METHODS

We conducted semistructured telephone interviews with 40 healthcare providers who use CVT to deliver services to veterans with SCI/D.

RESULTS

Factors related to workflow and communication were widely reported as implementation barriers. Coordinating logistics for CVT appointments was challenging, and effective communication between CVT team members across facilities was considered crucial. Providers also cited factors related to technical infrastructure, people, and organizational features, including the need for appropriate equipment, space, personnel, and support for using CVT equipment.

DISCUSSION

The implementation of CVT in the care of veterans with SCI/D was influenced by an interrelated set of social and technical factors. Key among them were social factors related to people, workflow, and communication, given that CVT supports healthcare teams interacting remotely in real time.

CONCLUSIONS

CVT implementation requires teams working together to negotiate a complex, distributed process across multiple sites. Such complexity places a premium on teamwork and communication among healthcare teams before, during, and after a CVT encounter.

Teleexercise for Persons With Spinal Cord Injury: A Mixed-Methods Feasibility Case Series

Background

Spinal cord injury (SCI) results in significant loss of function below the level of injury, often leading to restricted participation in community exercise programs. To overcome commonly experienced barriers to these programs, innovations in technology hold promise for remotely delivering safe and effective bouts of exercise in the home.

Objective

To test the feasibility of a remotely delivered home exercise program for individuals with SCI as determined by (1) implementation of the intervention in the home; (2) exploration of the potential intervention effects on aerobic fitness, physical activity behavior, and subjective well-being; and (3) acceptability of the program through participant self-report.

Methods

Four adults with SCI (mean age 43.5 [SD 5.3] years; 3 males, 1 female; postinjury 25.8 [SD 4.3] years) completed a mixed-methods sequential design with two phases: an 8-week intervention followed by a 3-week nonintervention period. The intervention was a remotely delivered aerobic exercise training program (30-45 minutes, 3 times per week). Instrumentation included an upper body ergometer, tablet, physiological monitor, and custom application that delivered video feed to a remote trainer and monitored and recorded exercise data in real time. Implementation outcomes included adherence, rescheduled sessions, minutes of moderate exercise, and successful recording of exercise data. Pre/post-outcomes included aerobic capacity (VO₂ peak), the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD), the Satisfaction with Life Scale (SWLS), and the Quality of Life Index modified for spinal cord injury (QLI-SCI). Acceptability was determined by participant perceptions of the program features and impact, assessed via qualitative interview at the end of the nonintervention phase.

Results

Participants completed all 24 intervention sessions with 100% adherence. Out of 96 scheduled training sessions for the four participants, only 8 (8%) were makeup sessions. The teleexercise system successfully recorded 85% of all exercise data. The exercise program was well tolerated by all participants. All participants described positive outcomes as a result of the intervention and stated that teleexercise circumvented commonly reported barriers to exercise participation. There were no reported adverse events and no dropouts.

Conclusion

A teleexercise system can be a safe and feasible option to deliver home-based exercise for persons with SCI. Participants responded favorably to the intervention and valued teleexercise for its ability to overcome common barriers to exercise. Study results are promising but warrant further investigation in a larger sample.

Channelrhodopsins-Their potential in gene therapy for neurological disorders

Recently, channelrhodopsins (ChRs) have begun to be used to manipulate the neuronal activity, since they can be targeted to specific neurons or neural circuits using genetic methods. To advance the potential applications in the investigation and treatment of neurological disorders, the following types of basic research should receive extensive financial support. The spectral and kinetic properties of ChRs should be optimized according to the application by generating variants of ChRs or exploring new rhodopsins from other species. These ChRs should be targeted to the specific types of neurons involved in the neurological disorders through a gene expression system using cell- or tissue-specific promoters/enhancers as well as gene delivery systems with modified virus vectors. The methods have to be developed to apply the genes of interest with safety and long-term effectiveness. Sophisticated opto-electrical devices should be developed. Appropriate primate animal model systems should be established to minimize the structural differences between small animals such as rodents and human beings. In this paper, we will review the current progress in the basic research concerned with the potential clinical application of ChRs and discuss the future directions of research on ChRs so that they could be applied for human welfare.

Predictors of changes in sentimental and sexual life after traumatic spinal cord injury

OBJECTIVE

To investigate changes and identify predictors in interpersonal functioning and sexual life after traumatic spinal cord injury (SCI).

DESIGN

Prospective, multicenter, follow-up observational study.

SETTING

Subjects at home, interviewed by phone during a 6-month period, 3.8 mean years after discharge from 24 centers participating in a previous epidemiologic prospective survey.

PARTICIPANTS

Subjects (N=403) with traumatic SCI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

DEPENDENT VARIABLES

satisfaction with sentimental life and satisfaction with sexual life compared with before the injury.

INDEPENDENT VARIABLES

demographic (age, sex, marital status, vocational status), SCI related (severity, level, bowel/bladder continence), car-driving ability, perceived quality of life (QoL), and impact of sentimental life, social integration, and vocational status on QoL.

RESULTS

Satisfaction with sentimental life was reportedly increased or the same as before SCI in 69% of the sample, but satisfaction with sexual life in only 31%. Lesser satisfaction with sexual life was reported by men than women (P=.002) and by married people than singles (P<.001). Significant predictors of sentimental life were perceived QoL and preserved driving ability (R(2)=.195). Bladder continence was positively associated with a better satisfaction with sexual life (R(2)=.368). Bowel continence did not remain a significant predictor of satisfaction with sexual life in multivariate analysis.

CONCLUSIONS

The challenge of a comprehensive rehabilitation of SCI, addressing the recovery of well-being including a satisfying sentimental and sexual life, requires identifying new issues that should be considered in up-to-date rehabilitation programs. The results indicate associations between driving ability and a better satisfaction with sentimental life. Further investigations are needed to explore whether the relationship is causative.